When Patrick Ward took the CIO role at Central Illinois Radiological Associates (CIRA), his charge was to create a unified workflow spanning 22 locations, seven distinct networks, at least nine vendors and a raft of dictation systems – then roll all of that into one portal, accessible to physicians via single-sign-on.
Oh, yes, and show a return on the investment that CIRA would reap from Ward’s work.
Ward spoke with Government Health IT Editor Tom Sullivan about the project, how he pulled it off and, in so doing, essentially enabled CIRA to participate in Illinois’ health information exchanges.
Q: It’s my understanding that you began by consolidating seven networks into one. Is that correct?
A: Yes. We are a sub-specialty hospital-based radiology group, so we have been primarily working off of hospital systems, but as our footprint grows we find ourselves having to access new hospitals remotely. Up until about 2008 the group enjoyed the benefits of working off the IT infrastructure that the hospitals provided, but as we grew we had to take on more and more IT infrastructure to accomplish those readings. That was usually done in reactive fashion. As a new site came on, for instance, we were contracted to read pediatric studies remotely; they would put in a network for those pediatric radiologists but general radiologists might not have access to that hospital.The person before me would order lines to be installed, try to negotiate with the hospital for a separate LAN for those physicians to access remote sites. And you can imagine requesting from one hospital to use it for prominent activity from another hospital. You know how that would go over.
Q: Like a lead balloon …
A: And as our scope of service increased we were being asked to provide point-to-point VPNs, so you can imagine working to install seven different point-to-point VPNs in one hospital. It became unmanageable. So when I came in the first thing I did was identify the need for a consistent corporate network infrastructure.
Q: You mentioned that you work with competing hospitals that were not real keen on you using their IT infrastructure to serve competitors. What is the set-up now and how did you overcome that?
A: What we’ve done now is put our own infrastructure in most of the hospitals. Even with that, the IT staff at these hospitals don’t want us running wires through these large campuses, so we negotiated with them to provide us with our own private VLANs that we could trunk to our network. So we are able to provide access to our physicians over our external and internal networks.
Q: One of the things I hear a lot about is a wave of consolidation in which small, rural, even mid-sized practices are aligning with hospitals if just to pay the bills. But it almost sounds as if CIRA has managed the opposite. How did you pay for this?
A: We have become more independent and we used all private funds. And that’s a great question because when the physician group enjoyed the fruits of the hospital IT infrastructure in the past, they didn’t have to pay for that. So introducing the cost to the group was very alarming to many of them. We were tasked with providing a business plan that would show the ROI, and that ROI was based on the efficiencies and productivity enhancements that our own infrastructure brought to the practice of radiology. They could read from one location everything they previously had to jump to seven different locations to read.
Q: So where was the ROI sweet spot?
A: It was really in the network consolidation. If we’re bringing in seven different networks you’re talking about DSL lines, cable modems and, in our case, we were dealing with the largest gateway we had installed was two bands apiece for three megs of access. So we opted for a metro Ethernet from AT&T that was fibre, so we were able to – in a mesh fashion – create 10MB gateways, meaning we increased the bandwidth by 300 percent immediately.
At first, it was not all consumed, but as we take up more and more sites we’re now approaching the point where it’s being consumed. We also looked at the productivity increases that came from consolidating networks at the hospital. So basically we improved the physicians' productivity at the remote sites. They were able to do more work in less time. Based on that value, we demonstrated how quickly we were able to pay for this.
Q: You’re talking about moving around radiology images – large, dense files. And you send those to an HIE, or how does it all work?
A: We are embarking on an application infrastructure right now that will integrate the EMRs and also the HIEs. We are building the application infrastructure out with the full intent of participating with the HIEs. Illinois is currently broken up into five HIE domains. There is one HIE still in the planning phase, so we may end up with six, we may stay at five. We are part of the Central Illinois HIE.
Q: How far along are you with that?
A: We are participating at the design level and we are still actually debating whether we are going to be a charter member. But I’ve had talks with the head of the Illinois HIE as well as the regional HIE about the image-sharing component. Image sharing is a huge issue and, in my opinion, it’s underspecified to handle a proper radiology workflow. So that’s why we’re debating the formal membership. We hope to have influence over the image sharing component of our regional HIE.
Q: Is the decision about whether to become a charter member a matter of funding, or something else entirely?
A: Partially. Illinois as a state took the federal funding available for this. So the systems for the regional HIEs are all going to be privately funded. And so we’re being asked to participate and we’ve been involved from the inception about making the case for image-sharing and some of the deficiencies that we see, but we want to have some assurances in our negotiations that we’re not just going to have the image-sharing format enforced on us. We need some assurances that we will have a voice and a very strong voice in how that’s going to work.
Q: What has been your biggest challenge in all of this?
A: I came in here with no infrastructure of my own. So I presented to the physicians that in order to accomplish the types of systems and the type of workflow that they wanted – which, by the way, was a unified worklist for all remote interpretations, we have 22 locations that we serve, we had seven distinct networks, nine vendors and a whole host of other dictation systems – so we needed to consolidate that workflow into a single sign-on, single portal to access that information so we could achieve those efficiencies. In order to accomplish that, the end goal, I described to the physicians that the first thing we needed to do was consolidate the IT infrastructure at the network level, which meant we had to build out our wide area network. Then we had to implement our own network, bringing in your typical local area network resources, domain controllers, security devices, firewalls, VPN connections, servers. Then we needed to build out a datacenter. Only then could we focus on those applications. So we started out ordering the WAN services. In the analogy of building a house, that was the foundation. Then the network services are the framing, the datacenter was the electrical and plumbing, and the applications the finish work.
Other Recent Government Health IT interviews:
Q&A: Telemedicine in the theater of war
Q&A: On the trials and tribulations of unlocking patient data
Q&A: How meaningful use is clashing with ICD-10
Q&A: Between the lines of NEJM EHR report, 'trust trumps tech,' authors say
3 questions with: A career DoD IT contractor in Afghanistan
Q&A: On ACOs and the 'cartelization' of healthcare
